Health inspection·February 29, 2024

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure one (Resident #165) of three residents reviewed for hospitalization was coded correctly on the minimum data set (MDS) at discharge. Residents Affected - Few Findings included: A review of Resident #165's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses included but not limited to Unspecified dementia, unspecified severity, with psychotic disturbance, muscle weakness (generalized), Unspecified lack of coordination, chronic kidney disease, stage 3b, bipolar disorder, unspecified, Major depressive disorder, recurrent, moderate and generalized anxiety disorder. A review of the Discharge - Return Not Anticipated Minimum Data Set (MDS) dated [DATE] revealed under Section A- Identification Information A. 2105 Discharge Status Resident #165 was discharged to 04 Short Term General Hospital. A review of progress notes revealed the following: - A progress note dated 01/23/2024 showed, Family has decided to transfer resident to [another local long term care facility] memory care unit on Friday 1/26/24 between 1 and 2 PM. Unit manager is aware. - A progress noted date 01/26/2024 showed, Resident sitting quietly in B wing TV room. Pt [patient] alert with confusion. Pt [patient] compliant with medications and care from staff. No s/s [signs or symptoms] of pain or distress noted. No negative behaviors noted at this time. Resident continues with PT [Physical Therapy] services. Resident scheduled to be transferring to another facility today between 11:00 am-12:00 pm. Will chart when pt leaves facility. No further issues noted at this time. - A progress note dated showed, Resident left facility via transport arranged by insurance to [local long term care facility] in [city, state]. [Family Representative] present as pt [patient] was being transferred. Report given to [Family Representative]. [Family Representative] will return back to facility for pt's [patient's] things tomorrow 1/27/24. - A progress note date 01/27/2024 showed, The [Family Representative] came to the facility, to collect resident's personal belongings, TV and mount. She stated, Thank you for all you have done for my mother. - A progress note dated 01/29/2024 showed, Social services spoke with [Family Representative]and (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 105515 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Plant City 701 N Wilder Rd Plant City, FL 33566 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)